Healthcare Provider Details

I. General information

NPI: 1285617621
Provider Name (Legal Business Name): JUAN M CUELLAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 NW 12TH AVE STE C5
MIAMI FL
33128-2205
US

IV. Provider business mailing address

219 NW 12TH AVE SUITE C5
MIAMI FL
33128-2205
US

V. Phone/Fax

Practice location:
  • Phone: 305-548-4063
  • Fax: 305-545-1515
Mailing address:
  • Phone: 305-548-4063
  • Fax: 305-545-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME87069
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: